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• The 9th Annual ISMP CHEERS Awards: And The Winners Are...
• Caution with slash marks.

  The use of slash marks may lead to errors as shown by a handwritten order example.

• Oral liquid given IV.

  A nurse who was unfamiliar with oral syringes mistakenly assumed that it was meant for IV administration.

• Human factors issue.

  In the course of setting the time and date on certain glucose meters, users may inadvertently change the units of measure from mg/dL to mmol/L.

• Daptomycin-dactinomycin confusion.

  A pharmacist mistakenly selected dactinomycin from a list of medications on the pharmacy computer system and mislabeled an IV bag of daptomycin.

• Company warning: Omacor-Amicar mix-ups.

  Reliant Pharmaceuticals issues a letter warning about potential mix-ups between these drugs.

• Draft label format guidelines for inpatient oral medications.

  A draft of guidelines covering the labels for oral solid medications that are dispensed and administered in the inpatient setting is posted on our website ( www.ismp.org/comments) for review and commentary.

• Special Announcements…
  ISMP Survey of IV Vincristine

If you work in an inpatient and/or outpatient healthcare facility that provides both IV and intrathecal chemotherapy, please complete our survey about the administration of IV vincristine.

December 15, 2005

• The 8th Annual ISMP CHEERS Awards: And the winners are...

• Hazard Alert.

  Another error involving the administration of tetanus toxoid instead of purified protein derivative (PPD) highlights the need for Sanofi Pasteur and FDA to pursue safer labeling and packaging of these products.

• Misspelling leads to mix-up.

  A handwritten order for ZEGERID (omeprazole) is misspelled and mistaken for ZESTRIL (lisinopril).

• Keypad “double bounce.”

  The inadvertent registration of the same number twice while programming the rate on pumps has led to overly rapid IV infusions.

• Fatal injection into the wrong port of a SynchroMed infusion pump.

  Nearly 1 g of morphine was mistakenly injected into the catheter access port of the implanted pump, which led to a patient’s death.

• Look for the new WHO report.

  The World Health Organization’s World Alliance for Patient Safety recently released Draft Guidelines for Adverse Event Reporting and Learning Systems.

• IV vincristine survey.

  If you provide oncology services please complete the brief survey at:

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